© 2003 The American Society for Nutritional Sciences
J. Nutr. 133:2950S-2952S, September 2003
Supplement: Nutrient Composition for Fortified Complementary Foods
Nutrient Composition of Fortified Complementary Foods: Should Age-Specific Micronutrient Content and Ration Sizes Be Recommended?1
Kathryn G. Dewey2
Department of Nutrition and Program in International Nutrition, University of California, Davis, CA 95616-8669
2To whom correspondence should be addressed. E-mail: kgdewey{at}ucdavis.edu.
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ABSTRACT
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Designing a fortified complementary food that meets the nutrient needs of all breast-fed children 6–24 mo of age is a challenge because of variability in the amounts of complementary foods consumed and the very high nutrient requirements of children < 12 mo of age. A single formulation targeted for infants 6–8 mo of age will result in excessive intakes of certain nutrients (e.g., calcium, iron and zinc) if consumed by children 12–23 mo of age (up to six times the recommended daily allowance (RDA) for iron), whereas a formulation targeted for children 12–23 mo of age will provide insufficient levels of nutrients for infants 6–8 mo of age (e.g., only 4–44% of the RDA for iron). Options for resolving this dilemma include developing 1) two or more different formulations for different age groups, 2) a high nutrient-density product but specifying a maximum ration per day or 3) a lower nutrient-density product and using a combination of approaches (e.g., a separate iron supplement) to reach the higher levels needed by infants. More information is needed on efficacy, costs and feasibility of these options.
KEY WORDS: • infant nutrition • complementary foods • iron • micronutrients • fortification
One of the challenges in developing fortified complementary foods is ensuring that the nutrient needs of infants and young children across the entire targeted age range (6–24 mo) are met. This is difficult because intakes of complementary foods may range 10-fold, from <25 g to >250 g of dry food per day, depending on the age of the infant and the amount of human milk and other foods consumed. The youngest infants (6–8 mo) generally consume the lowest amounts of complementary food, yet because of their rapid rate of growth and development their nutrient needs may be as high or higher than those of children in the older age ranges (depending on the nutrient). Meeting the nutrient needs of these younger infants via a relatively small quantity of food thus requires a high nutrient density (amount of nutrient per 100 kcal). However, use of the same formulation for children in the older age ranges, who eat more, may result in excessive intakes of certain nutrients. Therefore, it is important to consider whether age-specific formulations of fortified complementary foods are needed as well as the practical constraints that might limit the adoption of such a strategy.
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Risk of inadequate or excessive nutrient intakes if a single formulation is used
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To evaluate this issue, it is useful to estimate the range in nutrient intakes that would result if a single formulation of a fortified complementary food were developed for the entire age range of 6–24 mo. Two approaches have been taken to illustrate the dilemma (Tables 1, and 2). Table 1 shows what the situation would be if the fortification levels were chosen to meet the needs of children 12–23 mo of age who had an average human milk intake for that age [as defined in the 1998 World Health Organization document for developing country populations (1)]. The table illustrates the estimated intakes of four key nutrients (vitamin A, calcium, iron and zinc) if the same food was also consumed by infants 6–8 mo of age. Table 2 shows what the situation would be if the fortification levels were chosen to meet the needs of children 6–8 mo of age who had an average human milk intake for that age; it illustrates the nutrient intakes if the same food was also consumed by children 12–23 mo of age. In both tables, three different scenarios are shown based on whether human milk intake is low, average or high. The amount of complementary food consumed is based on the estimated energy needs from complementary foods for each age group (2), by level of human milk intake. These calculations assume that the fortified product is the only complementary food consumed, which is not likely in the real world but is useful for illustrative purposes. The estimated amount of each micronutrient provided by the fortified food is the product of energy intake from the food and the desired nutrient density for the age group for which it wasformulated (2). For each micronutrient, this product is then added to the estimated amount coming from human milk to derive the total intake. The percentage of the recommended nutrient intake [%RNI (3)] represented by the total is shown in the last column.
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TABLE 1 Amount consumed by 6–8 mo infants if product formulated for 12–23 mo infants with average human milk intake1
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TABLE 2 Amount consumed by 12–23 mo infants if product formulated for 6–8 mo infants with average human milk intake1
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Table 1 indicates that a food developed for the older age range (12–23 mo) is likely to fall well short of meeting the needs of younger infants for calcium, iron and zinc. For these nutrients, the worst case scenario occurs when there is high human milk intake at 6–8 mo, when the %RNI is 71% for calcium, 29% for zinc and only 4% for iron. Estimated vitamin A intakes are generally adequate except for infants with low human milk intake. Conversely, Table 2 indicates that a food developed for the younger age range (6–8 mo) results in excessive intakes of calcium, iron and zinc by the older children whereas vitamin A intakes of children with low human milk intake fall short of the RNI. The worst-case scenario for excessive intakes occurs when there is low human milk intake at 12–23 mo, when the %RNI is 176% for calcium, 621% for iron and 317% for zinc.
These two examples suggest that a single formulation is not ideal from the perspective of meeting nutrient needs and avoiding excessive intakes. The most extreme situation is for iron because iron requirements decrease with age. When the product is designed to meet iron needs of younger infants, the resultant very high iron intakes of older children are potentially risky (4). It is less clear whether risks are associated with calcium or zinc intakes that are two to three times higher than the RNI at this age. In these examples, vitamin A toxicity does not appear to be a problem.
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Strategies for meeting nutrient needs at different ages
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One strategy for dealing with the dilemma illustrated above is to develop two or more formulations of the fortified complementary food with different concentrations of micronutrients. This approach was taken in an intervention trial in Ghana (5). A product with high nutrient density was developed for infants consuming <60 g/d, and a product with lower nutrient density was used for infants consuming >60 g/d. Under the controlled conditions of the research trial, this approach worked well, but it is uncertain whether it would be practical on a larger scale. Clear educational messages would need to be developed to accompany the products and ensure that they were used for the correct target group.
Another approach is to develop a high nutrient density product but specify a maximum ration per day so that older children do not consume excessive amounts of certain nutrients. Feasibility trials would be needed to determine the degree of adherence to such instructions. If other fortified products are on the market and used simultaneously by some families, there might still be the risk of excessive nutrient intakes by some children.
A third approach is to develop a fortified food with lower nutrient density and use an additional, separate supplement to reach the higher levels needed by the younger infants (for example, a sprinkles product or a fat-based spread fortified with iron and zinc, or liquid iron and zinc supplements administered separately from meals). Liquid iron supplements may already be in use in certain populations because they are recommended for low birth-weight infants well before 6 mo of age. Promoting their use (perhaps in combination with zinc) for all targeted infants 6–12 mo of age might thus be a feasible strategy to complement the provision of a fortified food.
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Conclusions
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It is likely that there is no single best solution for all populations but that some combination of the strategies described above will be needed. Costs for the fortified complementary food are likely to be less if a product with a lower nutrient density is developed. However, if this mandates the creation of an additional program to meet nutrient needs of younger infants via supplements, the total cost of the combined approach may be greater than if a product with higher nutrient density is developed. At present, scientific information is not adequate to judge the potential risks associated with excessive intakes of certain nutrients. Until such information is available, a cautious approach would be to first evaluate the efficacy of a low-to-moderate nutrient density product and then increase the fortificant levels only if the clinical evidence suggests that such an increase is necessary.
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FOOTNOTES
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1 Presented as part of the technical consultation "Nutrient Composition for Fortified Complementary Foods" held at the Pan American Health Organization, Washington, D.C., October 4–5, 2001. This conference was sponsored by the Pan American Health Organization and the World Health Organization. Guest editors for the supplement publication were Chessa K. Lutter, Pan American Health Organization, Washington, D.C.; Kathryn G. Dewey, University of California, Davis; and Jorge L. Rosado, School of Natural Sciences, University of Queretaro, Mexico. 
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LITERATURE CITED
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1. World Health Organization (1998) Complementary feeding of young children in developing countries: a review of current scientific knowledge 1998 World Health Organization Geneva WHO/NUT/98.1.
2. Dewey, K. G. & Brown, K. H. (2003) Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr. Bull. 24:5-28.[Medline]
3. Joint FAO/WHO Expert Consultation (2002) Vitamin and mineral requirements in human nutrition 2002 World Health Organization Geneva .
4. Oppenheimer, S. J. (2001) Iron and its relation to immunity and infectious disease. J. Nutr. 131:616S-635S.[Abstract/Free Full Text]
5. Lartey, A., Manu, A., Brown, K. H., Peerson, J. M. & Dewey, K. G. (1999) A randomized community-based trial of the effects of improved, centrally processed complementary foods on growth and micronutrient status of Ghanaian infants at 6–12 mo. Am. J. Clin. Nutr. 70:391-404.[Abstract/Free Full Text]
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